Behavioral health and substance use disorder care

Behavioral Health coverage

Covered services include the treatment of behavioral health disorders provided by a hospital, psychiatric hospital, residential treatment facility, physician, or behavioral health provider including:

• Inpatient room and board at the semi-private room rate (your plan will cover the extra expense of a private room when appropriate because of your medical condition), and other services and supplies related to your condition that are provided during your stay in a hospital, psychiatric hospital, or residential treatment facility
• Outpatient treatment received while not confined as an inpatient in a hospital, psychiatric hospital, or residential treatment facility, including:

• Office visits to a physician or behavioral health provider such as a psychiatrist, psychologist, social worker, or licensed professional counselor (includes telemedicine consultation)
• Individual, group, and family therapies for the treatment of behavioral health disorders
• Other outpatient behavioral health treatment such as:
  • Partial hospitalization treatment provided in a facility or program for behavioral health treatment provided under the direction of a physician
  • Intensive outpatient program provided in a facility or program for behavioral health treatment provided under the direction of a physician
  • Skilled behavioral health services provided in the home, but only when all of the following criteria are met:
    • You are homebound
    • Your physician orders them
    • The services take the place of a stay in a hospital or a residential treatment facility, or you are unable to receive the same services outside your home
    • The skilled behavioral health care is appropriate for the active treatment of a condition, illness, or disease
  • Electro-convulsive therapy (ECT)
  • Transcranial magnetic stimulation (TMS)
  • Psychological testing
  • Neuropsychological testing
  • Observation
  • Peer counseling support by a peer support specialist

Substance use disorder treatment

Covered services include the treatment of substance related disorders provided by a hospital, psychiatric hospital, residential treatment facility, physician, or behavioral health provider as follows:

• Inpatient room and board, at the semi-private room rate (your plan will cover the extra expense of a private room when appropriate because of your medical condition), and other services and supplies that are provided during your stay in a hospital, psychiatric hospital, or residential treatment facility.
• Outpatient treatment received while not confined as an inpatient in a hospital, psychiatric hospital, or residential treatment facility, including:

• Office visits to a physician or behavioral health provider such as a psychologist, social worker, or licensed professional counselor (includes telemedicine consultation)
• Individual, group, and family therapies for the treatment of substance related disorders
• Other outpatient substance related disorders treatment such as:

• Partial hospitalization treatment provided in a facility or program for treatment of substance related disorders provided under the direction of a physician
• Intensive outpatient program provided in a facility or program for treatment of substance related disorders provided under the direction of a physician
• Ambulatory or outpatient detoxification which include outpatient services that monitor withdrawal from alcohol or other substances, including administration of medications
• Observation
• Peer counseling support by a peer support specialist

Behavioral health important note:

A peer support specialist serves as a role model, mentor, coach, and advocate. They must be certified by the state where the services are provided or a private certifying organization recognized by Aetna. Peer support must be supervised by a behavioral health provider.

Precertification

All inpatient and residential treatment for mental health and substance use disorder care must be pre-certified. The health care provider is responsible for obtaining pre-certification for network care. The participant is responsible for obtaining required pre-certifications for services at non-network facilities; if pre-certification for inpatient care is not obtained, a $500 penalty will be assessed for failure to pre-certify inpatient care at a non-network facility.

Partial hospitalization, intensive outpatient and outpatient care do not require prior authorization/precertification. However, non-routine outpatient care, such as Applied Behavior Analysis –ABA- and Transcranial Magnetic Stimulus –TMS, require prior authorization/precertification.